Treating advanced prostate cancer

By Nicole Brudos Ferrara

Advanced prostate cancer is cancer that has spread beyond the prostate to distant parts of the body. It is also called metastatic or stage 4 prostate cancer. While most advanced prostate cancer is incurable, treatments can slow or shrink the cancer, reduce symptoms and extend a person's life.

Recent advancements in diagnostic techniques and new treatments have improved the survival rate for advanced prostate cancer. "A variety of treatments, including hormonal treatments, can control the disease for a longer period, even if it's metastatic," says Oliver Sartor, M.D., a Mayo Clinic oncologist specializing in prostate cancer.

Here's what Dr. Sartor wants you to know about advanced prostate cancer and its treatment:

Prostate cancer treatment is highly personalized.

Prostate cancer treatment is individualized to each person and their cancer, says Dr. Sartor. "The thing that makes prostate cancer different from other cancers is the huge diversity in the disease. The treatment your neighbor had likely won't be the same treatment you'll have. Assessments and treatment are very personalized," he says.

If your biopsy confirms the presence of prostate cancer, a doctor will examine your cancer cells in a lab to determine how much they differ from healthy cells. A higher grade indicates a more aggressive cancer that is likely to spread quickly.

Genetic testing results could make you a candidate for targeted drug therapies, which attack specific chemicals in cancer cells, or immunotherapies, which help the body's immune system kill cancer cells, says Dr. Sartor. "We genetically test the DNA you're born with and the DNA from your tumor," he says.

Treatment planning also considers the parts of your body to which cancer has spread. "Maybe it's metastatic to the bones or the lymph nodes only. Maybe you've already had surgery, and you thought it was cured, and it came back. Each of these circumstances warrants individual assessment and treatment recommendations," says Dr. Sartor.

A PSA test may reduce advanced prostate cancer risk.

Detecting prostate cancer early, when treatment is most effective, may help you avoid advanced prostate cancer. One way to do that is through a PSA test.

A PSA test is a blood test that measures the amount of prostate-specific antigen (PSA) in your blood. PSA is a protein produced by both cancerous and noncancerous tissue in the prostate. A PSA test can detect high levels of PSA that may indicate the presence of prostate cancer. Ordinarily, small amounts of PSA circulate in the blood.

Other conditions, including an enlarged or inflamed prostate, also can increase PSA levels. This means that determining what a high PSA score means can be complicated. "It's a screening test that has some degree of controversy attached to it," says Dr. Sartor. "A PSA test may detect cancers that don't need to be treated. But it diminishes the risk of being diagnosed with advanced disease by detecting cancer early. I get a PSA myself."

"A PSA test may detect cancers that don't need to be treated. But it diminishes the risk of being diagnosed with advanced disease by detecting cancer early. I get a PSA myself."

Dr. Oliver Sartor

If you are diagnosed with low-grade prostate cancer that is expected to grow slowly, your cancer isn't causing symptoms, and it is confined to a small area of your prostate, you may not need immediate treatment. "Surveillance may be a good option for you," says Dr. Sartor. Active surveillance involves regular follow-up blood tests, imaging and, potentially, prostate biopsies to monitor the progression of your cancer.

"Age 50 is a reasonable age to start getting a PSA. But if you are African American or have a significant family history of prostate cancer or a genetic alteration that might predispose you to prostate cancer, then you should get one sooner," says Dr. Sartor.

Talk to your healthcare professional about when you should start PSA testing.

Radiopharmaceuticals offer new hope.

Prostate cancer cells rely on testosterone to help them grow. Hormone therapy, a treatment to stop your body from producing testosterone, is often used to shrink advanced prostate cancer and slow its growth. Therapy options include medications and surgery to remove the testicles. Prostate cancer that has stopped responding to hormone therapy is called castrate-resistant prostate cancer.

Some people with advanced castrate-resistant prostate cancer now have a new option: PSMA lutetium-177, also known as lutetium Lu 177 vipivotide tetraxetan, a radiopharmaceutical. Radiopharmaceuticals are drugs containing a radioactive substance used to diagnose or treat disease.

The Food and Drug Administration (FDA) approved PSMA lutetium-177 for adults whose prostate cancer:

• Produces a protein called prostate-specific membrane antigen (PSMA).
• Has been treated with a hormone therapy called androgen receptor pathway inhibition.
• Has been treated with drugs that stop cancer cells from dividing and growing, called taxane-based chemotherapy.

Healthcare professionals use an imaging test called a PSMA PET scan to determine if people are eligible for PSMA lutetium-177 treatment. Before undergoing this type of scan, you receive an IV injection of another radiopharmaceutical — a radioactive tracer that binds to the PSMA protein on prostate cancer cells. This tracer can be detected on the scan.

Dr. Sartor says determining eligibility for PSMA lutetium-177 involves carefully reviewing multiple factors, including previous treatments and the extent of the cancer's spread. "The patients who respond best have a lot of PSMA PET uptake and do not have liver involvement," he says. This means that if your PSMA PET scans show a significant amount of tracer in your cancer cells and your cancer has not spread to your liver, you're more likely to have a good response to the treatment.

Dr. Sartor stresses that this radiopharmaceutical may only prove effective for some people. "About a third of patients respond beautifully. About a third of patients don't respond at all, and the rest are in the middle," he says.

Research on PSMA lutetium-177 is advancing quickly and it may soon be an option for people with advanced prostate cancer before chemotherapy, says Dr. Sartor, who conducts clinical trials on radiopharmaceuticals. "I believe this therapy can safely benefit a significant number of patients who are not receiving it today," he says.

Learn more

Learn more about prostate cancer and find a clinical trial at Mayo Clinic.

Join the Prostate Cancer Support Group on Mayo Clinic Connect, an online community moderated by Mayo Clinic for patients and caregivers.

Also, read these articles:

• Prostate cancer screening: Should you get a PSA test?
• Prostate cancer: Family history, genetics and your risk
• Giving thanks for years of prostate cancer treatment: Kurt Glover-Ettrich
• Importance of exercise for men with prostate cancer

Conflict of interest or disclosure: Dr. Sartor is a paid consultant for Novartis, the maker of the drug lutetium Lu 177 vipivotide tetraxetan (Pluvicto).